ELFT Training Packages for Primary Care ‘ Common Childhood Mental Health Problems ’

1. ELFT Training Packagesfor Primary Care ‘Common Childhood Mental Health Problems’ Dr Justin WakefieldConsultant Child & Adolescent PsychiatristEast London NHS Foundation Trust 12.02.2015

2. Definition of a “problem” • Impairing abnormalities of behaviour, emotions and relationships • ABNORMAL in relation to • child’s age and gender • developmental stage • culture • persistence • extent of disturbance • severity and frequency • IMPAIRMENT • causes suffering to child/distress to family • social restriction • impedes the child’s development • effects on others

3. Which of these may be a problem? • A 3-year-old soiling during the dayA 7-year-old soiling during the day • Frequent temper tantrums aged 2 Frequent temper tantrums aged 10 • Severe anxiety at leaving mother at nursery gate aged 3Severe anxiety at leaving mother at secondary school gate aged 11

4. Importance of Child and Adolescent Mental Health • ½ of mental illness in adults has started before the age of 15

5. Aetiology • Child • boys • low intelligence • difficult temperament • physical illness • developmental delay • genetic factors • Family • traumatic stress • parenting issues • marital disharmony • maternal ill-health • parental psychiatric disturbance/substance misuse issues • abuse • Environment • peer relationship problems • social deprivation • school factors • stresses resulting from accidents

6. Aetiology • Consider whether child, family, environmental factors are: • PREDISPOSING • PRECIPITATING • PERPETUATING • WHAT IS PROTECTIVE AND AIDING RESILIENCE?

7. Common Childhood Mental Health Problems • Pre-school behavior problems • Conduct disorders • Emotional disorders • Adjustment disorders • Disorders of activity and attention • Failures of normal development • Attachment disorders and abuse • Adult-type disorders

8. Epidemiology Overall rates of problems - pre-school behaviour problems 22% - signifbehav or emotional problems aged 10 15% - signif psychological problems in adolescence 20% Prevalence of some psychiatric disorders • Conduct disorder 5% • Hyperkinetic disorder 1% • Anorexia nervosa 0.1-0.2% of adolescent girls • Autism 0.66%

9. 1. Pre-school behaviour problems • Feeding and eating • sleeping • temper tantrums • oppositional behaviour

10. 2. Conduct disorder • Disorder of behaviour characterised by repetitive and persistent pattern of dissocial, aggressive or defiant conduct. • Not just delinquency • Problem behaviours vary with development • New NICE guidelines

11. Conduct disorder - under 5s • aggression - physical and verbal • destructiveness • poor attention and concentration • frequent, severe tantrums

12. Conduct disorder - 5-12 years • lying • stealing • defiance • disruption in school • cruelty to animals • fire setting • solvent abuse

13. Conduct disorder - adolescence • truancy • delinquency • violence • sex offences • drug/alcohol/substance abuse

14. Conduct disorder – risk factors • boys >> girls • inner cities > rural areas • socio-economic disadvantage • family conflict and poor communication in the family • “difficult” temperament • Specific reading disability

15. 3. Emotional disorders • Disturbances of mood, persistent and not in response to a single identified stressor. • Disabling • Anxiety and fearfulness • Depression

16. Emotional disorders - symptoms • Fears - separation anxiety; social anxiety; specific phobias • Lack of pleasure; loss of interest; hopelessness; despair; sadness; tearfulness; lack of energy • Physical symptoms - abdominal pain, headaches • Fall off in school performance

17. Emotional disorders – risk factors • boys = girls • no association with socio-economic status • family factors - overprotection; parental anxiety • quiet, compliant temperament • no specific educational problems

18. School non-attendance • Truancy • School refusal (separation anxiety) • Child kept at home by parent • Fear of school (eg bullying)

19. 4. Adjustment disorders • Distress and emotional disturbance arising in a period of adaptation to a significant life change or to the consequence of a stressful life event • bereavement • divorce • physical illness

20. 5. Attention Deficit / Hyperactivity Disorder (ADHD) • overactivity • inattention • impulsivity • early onset • pervasive and persistent • boys >>> girls

21. 6. Failures of normal development : specific • speech and language ( receptive and expressive) • reading (dyslexia) • spelling • arithmetical skills • motor function (dyspraxia) • enuresis / encopresis

22. 6. Failures of normal development : pervasive • Autistic spectrum disorders - impaired quality of reciprocal social interaction - impaired communication - restricted, repetitive interests • Asperger’s Syndrome

23. 7. Attachment disorders • Marked distress and social impairment as a result of an extremely abnormal pattern of attachment, typically repeated changes of care-giver in early childhood • Reactive attachment disorder • Disinhibited attachment disorder

24. Abuse • physical (non-accidental injury) • emotional • sexual • neglect • Munchaussen Syndrome by Proxy??/ Factitious Induced Illness (FII)

25. 8. Adult type disorders • psychoses - schizophrenia; bipolar disorder • depression • post traumatic stress disorder • obsessive compulsive disorder • eating disorders • deliberate self harm

26. Assessment Main areas to cover in assessment. i) Description and history of main problems ii) Child’s peri-natal, developmental, medical, educational and social history iii) Family history including any psychological health problems and information regarding parents own experience of being parented iv) Mental state of the child v) Family communication and relationships An assessment also offers the opportunity to engage therapeutically with a family.

27. Formulation Following an assessment it is important to formulate the case. A formulation is a compact summary of relevant aspects of : i) presenting features ii) aetiological factors iii) diagnosis iv) management plan v) prognosis.

28. Diagnosis • There are two major diagnostic systems: • ICD- 10 Classification of Mental and Behavioural Disorders • DSM-5 Diagnostic and Statistical Manual of Mental Disorders • Both systems multi-axial. In ICD 10: • Axis I Clinical Syndrome • Axis II Disorders of Psychological Development • Axis III Mental Retardation • Axis IV Medical Illness • Axis V Abnormalities of psychosocial environment • Axis VI Level of disability

29. Treatment approaches in child psychiatry • Parental counselling • Psycho-education • Behaviour therapy • Cognitive-behavioural therapy • Family therapy • Pharmacotherapy • Individual psychotherapy • Group therapy • Liaison with other agencies • (education, social services, Paediatrics) • Usually out-patient • Also day hospital or in-patient

30. Prognosis • This depends on • nature and severity of the disorder • family and environmental context • treatment offered • Symptoms tend to be stubborn without treatment • Treatment effectiveness include • Behavioural work for behavioural problems • Methylphenidate in hyperkinetic disorder • Family work in anorexia nervosa